A nurse in the emergency department is receiving report on a group of clients. Which of the following clients should the nurse assess first?

A client who has Clostridium difficile and a temperature of 38.6° C (101.5° F)

A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10

A client who has left shoulder pain and S-T elevation on a 12-lead ECG

A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities

Answer and Explanation

The Correct Answer is C

A.   While a temperature elevation in a client with Clostridium difficile requires assessment, it is not as urgent as potential cardiac ischemia.
B.   Pain assessment in a client with a femur fracture is important but does not take priority over potential cardiac issues.
C.   Left shoulder pain with S-T elevation on an ECG can indicate myocardial infarction (MI), a life-threatening condition requiring immediate assessment and intervention.
D.   Orthostatic hypotension and pitting edema, while concerning, do not indicate an acute, life-threatening condition that requires immediate assessment in this scenario.

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Correct Answer is B

Explanation

A: While social workers can assist with many aspects of care, they may not always be able to provide legal representation or assistance.

B: While legal representation can be helpful, advance directives can be valid and legally binding documents even without it.
C: Verbal agreements are generally not sufficient for advance directives; written documentation is typically required.
D: While medical care can be initiated regardless of advance directives, it's important to inform the client that they can create directives without immediate legal assistance.

A. Helping clients understand health screenings covered by their insurance plans B. Educating clients about contraindications to specific immunizations C. Using an electronic messaging system to remind clients when to take medications D. Providing clients with information about the benefits of exercise

Correct Answer is C

Explanation

A. This task pertains more to secondary prevention, which aims to detect and treat HIV early through screenings and interventions.
B. This task is related to primary prevention, which aims to prevent HIV transmission through education and immunizations.
C. Tertiary prevention focuses on managing and reducing the impact of a disease or condition to prevent complications and promote quality of life. Using an electronic

messaging system to remind clients to take medications aligns with tertiary prevention by helping to manage HIV and prevent disease progression.
D. This task is more aligned with primary prevention, focusing on promoting healthy behaviors to prevent HIV transmission and disease development.

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A nurse in the emergency department is receiving report on a group of clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse Identify as tertiary prevention?

Correct Answer is C

Explanation

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